ISSUE BRIEF 10.23.18 Scientific Misconceptions and Myths Perpetuated in the 2017 Texas Legislative Session

Melody T. Tan, Baker Institute Graduate Intern Kirstin R.W. Matthews, Ph.D., Fellow in Science and Technology Policy, Center for Health and Biosciences

2017-18 (1.07%) (Matthews and Tan 2018; EXEMPTIONS IN TEXAS TX DSHS 2018b). and vaccine exemptions have Vaccine exemptions were a become increasingly contentious issues in controversial subject during the 85th Texas Texas, with pro- and anti-vaccine groups legislative session in 2017. They were contesting several vaccine-related bills addressed in House Bill 2249 (HB 2249) and in the state legislature during the 2017 House Bill 1124 (HB 1124). While neither of session. There are two types of exemptions these bills moved forward, the arguments for vaccines: medical and nonmedical. presented by witnesses during the hearings Medical exemptions are issued by a for the bills provide insight into key physician, who states that the required objections raised by anti-vaccine advocates. vaccine is “medically contraindicated or HB 2249, “requirements for and the poses a significant risk to the health and transparency of epidemiological reports well-being” of a child or someone in their and exemption information household (TX DSHS 2018a). Examples and reports,” required the state to report of medical contraindications include NME rates at the school level, as opposed having HIV/AIDS, a compromised immune to the current school district level. This bill system, or a life-threatening allergy to received a hearing on April 11, 2017, and any component of the vaccine (CDC 2018a; was voted out of the committee, although Rubin et al. 2014). These exemptions, it was not voted out of the chamber by the With adherence to unless otherwise specified, are only valid end of the session (Texas HB 2249 2017). the recommended for one year (TX DSHS 2018a). In contrast, This hearing included 35 witnesses with 12 immunization schedule, stating support, 22 opposing the measure, nonmedical exemptions (NMEs) can be herd immunity can be requested by a child’s legal guardian and one witness testifying ‘on’ the bill. who refuses based on HB 1124, “claiming an exemption from maintained, protecting personal beliefs, including religious and required for public school the entire population conscientious objections. Unlike medical students,” intended to make it easier to from disease. exemptions, NMEs are valid for two years. obtain vaccine NMEs. This bill received a Medical and nonmedical exemptions to hearing on April 25, 2017, but subsequently vaccine requirements have been permitted died without a committee vote at the in Texas since 1972. In 2003, the state end of the session (Texas HB 1124 2017). started allowing conscientious exemptions; Twenty-nine witnesses were reported as since then, Texas shows a steady increase testified in the hearing, with one stating in the number of NMEs from 2,314 (0.08% support, 24 opposing the measure, and the of all students) in 2003-4 to 56,738 in remaining four witnesses testifying ‘on’ the RICE UNIVERSITY’S BAKER INSTITUTE FOR PUBLIC POLICY // ISSUE BRIEF // 10.23.18

with one dose and 97% effective with FIVE MAJOR MISCONCEPTIONS ABOUT VACCINES two doses (CDC 2018c). The diphtheria, tetanus, and pertussis (DTaP) vaccine is 1. Vaccines are ineffective. 80-90% effective (CDC 2017a). The 1995 implementation of a program 2. Herd immunity is a myth or does not exist. for varicella (chicken pox) reduced incidence, hospitalizations, and deaths by about 90% 3. Vaccines ‘shed’ and cause the spread of disease, endangering the in the first decade after implementation medically fragile. (Leung, Bialek, and Marin 2015; Lopez et al. 2011; Marin, Zhang, and Seward 2011). 4. The consequences of vaccine-preventable diseases are minor, while However, witnesses often cited the vaccines frequently cause injury and death. relatively low effectiveness of the , with one witness noting that “the 5. Vaccine-exempt children are not spreading disease. 2015-2016 flu shot was only 48% effective” (HB 1124-08).1 While the effectiveness of the flu vaccine is low, it is an outlier not the norm (CDC 2018d; Jackson et al. 2017). The bill. Several witnesses were against school- influenza virus mutates quickly, and a new mandated vaccines as well as the bill itself. version emerges annually. Unfortunately, In this issue brief, we describe the the strain used for the influenza vaccine is key scientific misconceptions presented developed months before flu season starts by vaccine opponents during the witness based on researchers’ best predictions, and testimonies for HB 2249 and HB 1124. the strain used for vaccines does not always Transcripts from the two hearings were match the strain that later circulates (WHO reviewed, and scientific misconceptions 2017). Therefore, effectiveness rates of flu and misinformation were identified, vaccines vary and are not as high as other analyzed, and compared to current nonseasonal vaccines, such as those for evidence in the scientific literature. Our DTaP and MMR. results found that vaccine opponents One witness further implied that promoted several scientifically questionable vaccines can increase disease rates, saying ideas, with five major misconceptions “from the time they started the [polio] identified: 1) vaccines are ineffective, 2) vaccine trials, you see a spike up [of the >99% disease]” (HB 2249-08). However, this is herd immunity is a myth, 3) vaccines ‘shed' Measles incidents decreased and cause the spread of disease, 4) the false (see Figure 1). Polio data annually from 530,217 to 85 impacts of vaccine-preventable diseases show an overall decrease in U.S. paralytic after the introduction of are minor, and 5) vaccine-exempt children polio cases after both the introduction of the MMR vaccine. are not spreading disease. the inactivated poliovirus vaccine in 1955 and the oral poliovirus vaccine in 1961 (Nathanson and Kew 2010). MISCONCEPTIONS Several witnesses also challenged the effectiveness of vaccines, asserting MISCONCEPTION 1: Vaccines are ineffective. that “vaccination does not always REALITY: Childhood vaccines have high rates provide immunity” and “vaccines do not of effectiveness. immunize; they interfere with the common One common misconception repeated immunological response to the respected during the witness testimonies was that diseases after subsequent exposure” (HB vaccines are ineffective. On the contrary, 2249-05; HB 2249-03). One of these most vaccines have extremely high witnesses stated that “two of my children effectiveness rates. The inactivated polio had the full HepB schedule of vaccines, and vaccine is 90% effective with two doses both them have lab confirmation of zero and 99-100% effective with three doses antibodies to HepB” further claiming that (CDC 2018b). The measles, mumps, and “they are also not immune” (HB 2249- 05). Several others were concerned that 2 rubella (MMR) vaccine is 93% effective SCIENTIFIC MISCONCEPTIONS AND MYTHS PERPETUATED IN THE 2017 TEXAS LEGISLATIVE SESSION

children who get vaccinated but fail to the 1960-70s through a mass vaccination produce antibodies or gain immunity will program in endemic countries (Lane 2006). become immunocompromised. Research on Japanese school children These statements highlight a vaccinated for influenza demonstrated misunderstanding of how vaccines and protection and reduced influenza mortality the immune system work. Vaccines among older members of the population. mimic an so that the body learns Furthermore, after vaccination requirements how to fight off a future infection. After were removed and vaccination rates among vaccination, the body stimulates immune schoolchildren decreased, excess mortality cells (T and B lymphocytes) to mount a rates increased (Reichert et al. 2001). specific adaptive immune response against Another misconception about herd the virus, which helps the body remember immunity is that it is only a theory and does how to defend against future not exist in reality. This argument appeared (Alberts et al. 2015). Scientific research and more frequently during the legislative experiments do not support the belief that hearings. One witness alleged that because vaccination causes immunosuppression. vaccines wear off, the population does not In fact, it is generally recommended that benefit from herd immunity, claiming that inactivated vaccines can be safely given to “if all adults in this room right now have immunocompromised patients (Kroger et al. not continued to be vaccinated, receive 2011; Sobh and Bonilla 2016). boosters...then we are not all immunized” (HB 1124-08). Similarly, another witness MISCONCEPTION 2: Herd immunity is a myth claimed that “vulnerable children...are or does not exist. already surrounded by numerous adults REALITY: Having a significant portion of the public immunized protects people who are immunocompromised, including infants, the FIGURE 1 — PARALYTIC POLIO CASES DECREASE IN THE U.S. AFTER elderly, and patients undergoing treatment THE VACCINE WAS INTRODUCED IN 1955 (SHOT) AND 1961 (ORAL) for immune diseases and cancers.

Herd immunity occurs when the prevalence 1955 of immunity in a vaccinated population Inactivated poliovirus vaccine prevents transmission of infectious agents, 10.0 thereby offering indirect protection to unvaccinated individuals. Another recurring theme in the witness testimonies is skepticism about herd immunity: “herd 1961 Oral poliovirus vaccine immunity is a myth; the math simply does 1.0 not work” (HB 2249-03). There are two main misconceptions about herd immunity. One misconception is that the concept of herd immunity is invalid; however, numerous studies have shown that the herd effect has helped to reduce rates 0.1 of disease, including smallpox, pertussis, 1973 influenza, and pneumococcal disease Eradication of wild poliovirus Number of paralytic polio cases (thousands) (Kim, Johnstone, and Loeb 2011). After the became available in the 1940s, a reduction in pertussis was observed 0.01 not only among vaccinated infants and adults but also among unvaccinated infants because herd immunity reduced the virus's reach (Taranger et al. 2001). Herd immunity SOURCE (Nathanson and Kew, 2010) also contributed to smallpox reduction in 3 RICE UNIVERSITY’S BAKER INSTITUTE FOR PUBLIC POLICY // ISSUE BRIEF // 10.23.18

in the school system who don't have the to the mumps virus, vaccination reduces schedule of vaccines that kids get” (HB shedding to levels significantly lower than 2249-13). that of infected, unvaccinated individuals. It is true that vaccine protection can (Fanoy et al. 2011; Gouma et al. 2016). wane; however, this is why there is a Yet another witness argued that “polio recommended immunization schedule was eradicated in 1979. Since then every for adults. For instance, a booster for the single case of polio has been brought into DTaP vaccine is recommended every 10 this world through vaccines” (HB 1124-08). years (CDC 2018e). With adherence to the This statement about polio ‘eradication’ is recommended immunization schedule, herd misleading. Since 1979, no polio cases have immunity can be maintained, protecting the originated in the United States. However, entire population from disease. polio is still present globally. New polio cases since 1979 have been brought into the U.S. MISCONCEPTION 3: Vaccines ‘shed’ and by travelers with polio, not through vaccines 100% (CDC 2017b). cause the spread of disease, endangering Polio incidents decreased the medically fragile. MISCONCEPTION 4: The consequences annually from 16,316 to 0 REALITY: Most vaccines do not shed, and of vaccine-preventable diseases are minor, after the introduction of there is extremely minimal risk of infection while vaccines frequently cause injury the . from the few that do shed. and death. A few witnesses argued that vaccines are REALITY: There are severe consequences of harmful to the medically fragile because vaccine-preventable diseases, while vaccine of ‘vaccine shedding,’ which is the idea risks are extremely minimal. that vaccines release the virus into the population. According to one witness, “a Vaccine opponents also used the argument recent study suggests that a plausible that the consequences of vaccine- explanation for whooping cough resurgence preventable diseases are relatively is actually asymptomatic transmission from insignificant. Measles is often used as an the recently vaccinated,” although they did example for this argument. One witness not share enough detail of the publication said that “on a local TV channel recently, a for the authors locate the article (HB 2249- M.D. described measles as a lethal disease— 05). This witness concluded that children how misleading. Historically in the US and “who receive live vaccines can put the other industrialized nations, measles is medically fragile at risk due to shedding.” benign. That means the majority of kids Another witness, who self-identified as experience no complications, recover >99% immunocompromised after receiving two efficiently, typically enjoy lifetime of bone marrow transplants, said, “every time actual immunity as a result” (HB 2249- Rubella incidents decreased I have gotten sick, it is because I have been 03). While measles is no longer endemic annually from 47,745 to 1 in contact with a child or an adult who is in the U.S., the decreased mortality from after the introduction of recently vaccinated” (HB 2249-14). measles is a result of vaccination. Prior to the MMR vaccine. Overall, the occurrence and risks of widespread vaccination, more than half a vaccine shedding are misunderstood. Of the million cases were reported annually (Table vaccines required by TX DSHS, only the MMR 1). Due to systematic vaccinations, the and oral polio vaccine are live attenuated number of cases has been reduced to only vaccines, which contain weakened forms 85 incidents in 2016, with the last reported of the virus. Other vaccines are either measles death in the U.S. occurring in inactivated, subunit, or vaccines, 2015 (Fox 2015). Measles infections cause which do not contain live viruses and severe complications including bronchitis, therefore cannot shed the virus (WHO, n.d.). pneumonia, encephalitis, and pregnancy Shedding from the MMR and the oral polio problems that led to 11,000 hospitalizations vaccine is unlikely, and the risk of infection is and 123 deaths in the 1989-91 measles extremely minimal. Studies show that in the resurgence (Mayo Clinic 2018; Orenstein, rare case a vaccinated individual is exposed Papania and Wharton 2004). Similar data on 4 SCIENTIFIC MISCONCEPTIONS AND MYTHS PERPETUATED IN THE 2017 TEXAS LEGISLATIVE SESSION

TABLE 1 — DISEASE INCIDENCE AND VACCINATION RATES FOR THE U.S. AND TEXAS

Average Annual Kindergarten Kindergarten Reported Disease Vaccine Disease Incidence Vaccination Rate Vaccination Rate Incidence (U.S., prior to vaccinea) (U.S., 2016) (Texas, 2016) (U.S./Texas, 2016)

DTaP

Diphtheria 21,053 (1936-45) 94.5% 97.15% 0 / 0

Tetanus 580 (1974-79) 34 / 2

Pertussis 200,752 (1934-43) 17,972 / 1286

MMR

Measles 530,217 (1953-62) 94% 97.34% 85 / 1

Mumps 162,344 (1963-68) 6369 / 191

Rubella 47,745 (1966-68) 1 / 0

Others Vaccines

Polio (paralytic) 16,316 (1951-54) 94.4% 97.31% 0 / 0 86.1% (19-35 Hepatitis A 117,333 (1986-95) 96.78% 2007 / 139 months)e Hepatitis B 66,232 (1982-91) 95.5% 97.88% 3218 / 156

Varicella 4,085,120 (1990-94) 96.5% 96.53% 8956c / 1341

Meningococcalb 4100 (2003-07)d 82.2%f 97.25% 375 / 23

NOTES aThe years in parentheses reflect the time period data were obtained; bthe is required at 13 years of age/7th grade; c these data include incidents reported (morbidity and mortality) and might not include all incidents since symptoms could be minor SOURCES Average Annual Disease Incidence, US Prior to Vaccine: (Roush, et al. 2007), d(Thigpen et al. 2011); Vaccination Rate, U.S. 2016: (CDC 2017c, eCDC 2017d, fCDC 2018f); Vaccination Rate, Texas 2016: (TX DSHS Immunization Unit 2017); Reported Incidence, U.S. 2016: (CDC 2017e); Reported Incidence, Texas 2016: (TX DSHS 2017) other vaccine-preventable diseases can also risk for GBS, encephalitis, or anaphylaxis be found (Table 1). was found (Kawai et al. 2014). In contrast, Witnesses also consistently mentioned GBS has been associated with Zika and that vaccines frequently cause injury and influenza infection (Nóbrega et al. 2018). The death. In previous years, this discussion risk of vaccine-associated GBS is estimated focused on autism, but in the 85th at less than 1 case per million immunized legislative session other diseases were individuals, which is significantly less than highlighted as well, especially Guillain-Barre the risk of vaccine-preventable diseases Syndrome (GBS), an autoimmune disorder. (Principi and Esposito 2018). However, scientific research indicates that, Witnesses also expressed fears that with rare exceptions (namely the 1976 swine vaccines contain toxic ingredients including influenza vaccine), there have only been “aborted fetal tissue, aluminum, mercury, coincidental associations between vaccines Polysorbate 80” and that “vaccines cause and GBS (Haber et al. 2009; Principi and brain inflammation, brain damage, chronic Esposito 2018). After surveilling more than arthritis and a continuing list of autoimmune 3.6 million doses of inactivated influenza and neurological disorders” and in some vaccine and 250,000 first doses of live cases, death (HB 2249-04; HB 2249-03). attenuated influenza vaccine, no increased The reason aborted fetal tissue is thought to 5 RICE UNIVERSITY’S BAKER INSTITUTE FOR PUBLIC POLICY // ISSUE BRIEF // 10.23.18

be a vaccine ingredient is because several between vaccination and SIDS. The Vaccine vaccines were created using the WI-38 cell Adverse Event Reporting System (VAERS) line, which was originally developed in 1962 and the National Academies of Science, from the lung tissue of an aborted fetus. The Engineering, and Medicine (NASEM) both WI-38 cell line has been rigorously tested concluded that trends in the number of SIDS for safety, and the actual cells are not deaths reported to VAERS followed SIDS found in vaccines. As a result of using the rates in the general U.S. population, and any WI-38 cell line for vaccine development and association between vaccination and SIDS is other medical advancements, an estimated coincidental (Silvers et al. 2001; NASEM 2003). 10.3 million lives have been saved globally Furthermore, some witnesses drew the (Olshansky and Hayflick 2017). conclusion that deaths caused by vaccine A few vaccines do include aluminum injuries outnumber deaths from vaccine- salts, mercury, and Polysorbate 80 as inactive preventable causes. One specifically listed ingredients (FDA 2018). However, these off statistics from unidentified sources, ingredients have been proven to be safe at remarking, “in 2014, there was recorded 629 the levels used in vaccines. Aluminum levels deaths from vaccines; natural causes of those in infants from vaccine adjuvant and food disease were 77 deaths” (HB 1124-08). The sources are safely below risk levels (Mitkus witness did not realize that vaccines are the et al. 2011). The only vaccine ingredient reason so few people are dying of vaccine- that contains mercury is thimerosal, a preventable diseases (Table 1). Overall, the preservative used to prevent the growth of risks of vaccines are minimal compared to bacteria. Today, thimerosal is not used in the disease mortality that is prevented any of the required childhood vaccines in the by vaccination. U.S. (CDC 2013). Furthermore, there has been 100% no link discovered between thimerosal and MISCONCEPTION 5: Vaccine-exempt children autism (Andrews et al. 2004; Fombonne et al. are not spreading disease. Diphtheria incidents decreased 2006; Hviidet al. 2003; IOM 2004; Thompson REALITY: Vaccine outbreaks are primarily annually from 21,053 to 0 et al. 2007). In addition, Polysorbate 80 is an occurring among unvaccinated populations. after the introduction of additive commonly used in food products, the DTaP vaccine. including bread, oil, and chocolate. The U.S. Several witnesses alleged that children with Food and Drug Administration (FDA) set the vaccine exemptions are not responsible acceptable daily intake (ADI) of polysorbates for spreading disease. Addressing HB 2249, at 1500 mg per person per day, and an one witness argued that “the bill makes extensive toxicology study conducted in a misguided presumption that children Japan set the ADI at 10 mg per kg body weight with vaccine exemptions are responsible per day (Food Safety Commission of Japan for spreading disease, and that vaccinated 2007). The amount of Polysorbate 80 used children are protected and unable to in vaccines is significantly less than either of transmit disease” (HB 2249-05). To support these ADI recommendations. For instance, this claim, another witness stated that each dose of the HPV vaccine only has 0.05 “current outbreaks seem to have occurred mg of Polysorbate 80 (Children’s Hospital of a lot among highly vaccinated population” Philadelphia 2018). (HB 2249-12). A different witness mentioned One witness suggested that vaccines that in “the recent mumps outbreak, we were linked to sudden infant death syndrome wrote to the health department, found (SIDS), stating that “90% of [SIDS] cases, out that most of these mumps outbreaks, they happen within 2-7 days of a round of almost all of the kids were fully vaccinated” vaccines. There is a lot of evidence of cases (HB 2249-13). Some argued that “exposure that we are losing 3-4,000 infants a year to potential pathogens is ubiquitous,” to vaccine fatalities that is a 2 or 3 times as and therefore both “vaccinated and many loss of children’s lives of all ages to all unvaccinated children... develop and spread childhood diseases combined in the years [diseases] to others” (HB 2249-03). leading up to vaccine” (HB 2249-03). There These ideas are contrary to the scientific is no scientific basis for the purported link literature. In a review of 1416 measles cases, 6 SCIENTIFIC MISCONCEPTIONS AND MYTHS PERPETUATED IN THE 2017 TEXAS LEGISLATIVE SESSION

56.8% had no history of measles vaccination They are a critical tool for public health and (Phadke et al. 2016). During the five largest should be encouraged and promoted by the U.S. pertussis outbreaks impacting an entire state legislature by increasing access, not state, 24-45% of affected individuals were disparaged by allowing myths to perpetuate unvaccinated or undervaccinated individuals. unchallenged. While there were outbreaks among highly vaccinated populations, these were attributed to waning immunity. REFERENCES

For a full list of references, please visit CONCLUSIONS AND https://bit.ly/2CZ8Dqt. RECOMMENDATIONS

Analysis of the anti-vaccine witness ACKNOWLEDGMENTS statements presented during the 85th Texas Legislative Session in 2017 revealed five The authors would like to acknowledge the recurring misconceptions: 1) vaccines are help of SuJin Kang and Richard Bui, who ineffective, 2) herd immunity is a myth, reviewed videos and transcripts from the 3) vaccines ‘shed' and cause the spread 2017 hearings and conducted literature of disease, 4) the impacts of vaccine- reviews. We would also like to acknowledge preventable diseases are minor, and 5) Sharon Tsao and Jonathan Picker, who vaccine-exempt children are not spreading edited the manuscript. disease. Each of these myths is inaccurate and unscientific. Furthermore, the witnesses failed to use accurate scientific data to ENDNOTES justify them. The few witnesses who did try 1. Witnesses were de-identified and to cite research grossly misunderstood or See more issue briefs at: numbered based on the hearing they www.bakerinstitute.org/issue-briefs misinterpreted the data. participated in. For full hearing testimonies Given these misconceptions, there is a see (Texas HB 2249) and (Texas HB 1122). This publication was written by a clear need to increase the awareness of both researcher (or researchers) who policymakers and the general public to the participated in a Baker Institute project. positive impact of vaccines, the negative AUTHOR Wherever feasible, this research is reviewed by outside experts before it is consequences of an undervaccinated Melody T. Tan is a graduate intern for the released. However, the views expressed public, and how policies can help influence herein are those of the individual Baker Institute Center for Health and vaccination rates within Texas. One way author(s), and do not necessarily is to encourage broad public participation Biosciences and a Ph.D. candidate in the represent the views of Rice University’s in discussions on vaccines that involve Department of Bioengineering at Rice Baker Institute for Public Policy. physicians, scientists, parents, and University. Her scientific research is focused on improving oral cancer diagnosis. © 2018 Rice University’s Baker Institute students—especially those who are at-risk for Public Policy by being around undervaccinated children. In addition, scientists and doctors should Kirstin R.W. Matthews, Ph.D., is a fellow in This material may be quoted or share and discuss publicly available data and science and technology policy at the Baker reproduced without prior permission, research on vaccines and their impacts on Institute. She is also a lecturer in the Wiess provided appropriate credit is given to the author and Rice University’s Baker public health. School of Natural Sciences and a joint faculty Institute for Public Policy. Without strong public support for member in the Department of BioSciences at Rice University. Her research focuses on vaccines and vaccine research, we run the Cite as: risk of allowing more people to opt-out for ethical and policy issues related to biomedical Tan, Melody T., and Kirstin R.W. nonmedical reasons, thereby increasing the research and development. Matthews. 2018. Scientific risk of vaccine-preventable disease and Misconceptions and Myths Perpetuated in the 2017 Texas Legislative Session. decreasing overall public health. Vaccines are Issue brief no. 10.23.18. low-cost solutions to often expensive and Rice University’s Baker Institute debilitating illnesses. They reduce the public for Public Policy, Houston, Texas. financial burden and increase public health. 7